estrategia en dolor abdominal urgencia apendicitis score (dr s rodriguez
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ESTRATEGIA EN DOLOR
ABDOMINAL
CONSULTA QUIRURGICA
Santiago RodríguezCirujano pediatra
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Charla difícil!
Santiago RodríguezCirujano pediatra
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CLINICALABORATORIO
IMAGENESANALGESIA ANTES DE VALORACION
CUANDO CIRUJANOCIRUGIA EMERGENCIA URGENCIA
PREGUNTAS ???
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Los hallazgos clínicos pueden ser utilizados para guiar la toma de decisionesEn la estratificación del riesgo posible de apendicitis?.Recomendación Nivel A – NingunaNivel B Utilizar los hallazgos clínicos para estratificar y orientar las decisiones de las pruebas y solicitar valoración.Nivel C – Ninguna.
Annals of Emergency Medicine Volume 55 N 1 – Enero 2010
Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis
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Clínica
MEDICO GENERAL
PEDIATRA
CIRUJANO PEDIATRA
Apendicitis negativasApendicitis perforadasPerforadas con dx previoEventos adversos
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2009REVISION 207 OPERADOS.
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HUEM - 2009REVISION 207 OPERADOS.
EDAD : 9 Años 9m
Masculino 60%Femenino 40%
Tiempo evolución 27 horas
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Cuadro clínico Operados 207 (%)
Dolor abdominal 205 (99)Vómitos 140 (68)Fiebre 112 (55)Anorexia 32 (16)Lengua saburral 16 (8)Adinamia 16 (8)
Diarrea 25 (12)
Dolor FID 176 (85)
McBurney 73 (35)Rovsing 50 (24)Blumberg 41 (20)
HUEM - 2009REVISION 207 OPERADOS.
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(LR) COCIENTE DE PROBABILIDAD ASOCIADA
5 – 10 Presencia moderada aumenta la posibilidad de la enfermedad.
2 – 5 Puede aumentar la posibilidad de la enfermedad.
< 2 No puede cambiar la posibilidad de la enfermedad
(+) Mayor riesgo de que la enfermedad se produzca
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Dolor cuadrante inferior derecho 7,31 – 8,46Dolor anterior al vómito 2,76Migración del dolor 3,18Anorexia 1,27Nauseas 0,69 – 1,20 Vómitos 0,92
(LR) COCIENTE DE PROBABILIDAD ASOCIADA
5 – 10 Presencia moderada aumenta la posibilidad de la enfermedad.
2 – 5 Puede aumentar la posibilidad de la enfermedad.
< 2 No puede cambiar la posibilidad de la enfermedad
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Defensa Voluntaria 3,76Dolor F.I.D. 2,30Psoas 2,38Blumberg 3,70Fiebre 1,94Dolor rectal 0,83 – 5,34Dolor igual antecedente 1,50
(LR) COCIENTE DE PROBABILIDAD ASOCIADA
5 – 10 Presencia moderada aumenta la posibilidad de la enfermedad.
2 – 5 Puede aumentar la posibilidad de la enfermedad.
< 2 No puede cambiar la posibilidad de la enfermedad
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IrritabilidadLetargoRespiración rudaDolor al caminar (cojera)
(LR) COCIENTE DE PROBABILIDAD ASOCIADA
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Cuadro Hemático (163)
Leucocitos> 20.000 18%>15.000 < 20.000 43%>10.000 < 15.000 30%< 10.000 9%
HUEM - 2009REVISION 207 OPERADOS.
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Cuadro hemático 1,59 – 2,7Proteína C 4,24 Parcial de Orina
COMBINACION
(LR) COCIENTE DE PROBABILIDAD ASOCIADA
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Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002;37:877-81.
Alvarado A. A practical score for the early diagnosis of acute appendicitis. AnnEmerg Med 1986;15:557-64.
Ohmann C, Yang Q, Franke C. Diagnostic scores for acute appendicitis. AbdominalPain Study Group. Eur J Surg 1995;161:273-81.
Ohmann C, Franke C, Yang Q. Clinical benefit of a diagnostic score for appendicitis:results of a prospective interventional study. German Study Group of AcuteAbdominal Pain. Arch Surg 1999;134:993-6.
SCORE
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Clinical Finding PointsTenderness in the right lower quadrant 4.5Rebound tenderness 2.5No difficulty with micturition 2.0Steady pain 2.0Leukocytosis (≥ 10,000 white blood cells per mm3 [10 109 per L])�
1.5
Age less than 50 years 1.5Migration of pain to the right lower quadrant 1.0Abdominal rigidity 1.0
Total: 16
Ohmann Score for the Diagnosis of Appendicitis in Adults and Children Older Than Six Years
Ohmann C, Franke C, Yang Q, for the German Study Group of Acute Abdominal Pain. Clinical benefit of a diagnostic score for appendicitis: results of a prospective nterventional study. Arch Surg. 1999;134(9):994.
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Migración del Dolor 1Dolor en FID con el movimiento 2Dolor en FID a la palpación 2Anorexia 1Nausea / Vómito 1Fiebre 1
Leucocitosis 1Neutrofilia
P.C.R. 1
Puntuación de Samuel para Diagnostico de Apendicitis
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Valoraciones 1170770 Cirugía
apendicitis 95.6% perforadas 20% no apendicitis 4.4%
400 No CirugíaIdiopático 62%Gastroenteritis 12%Estreñimiento 21%Adenitis – IRA 5%
Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002;37:877-81.
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EVALUACIÓN DE PACIENTES CON DOLOR ABDOMINAL AGUDO
RIESGO DE APENDICITIS
Bajo < 5% Moderado Alto
Samuel < 2 Samuel > 7
ECO -TAC
Negativo PositivoObservación
SalidaValoración
Cirujano
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radiologists sometimes seem to say that “all children with appendicitis get imaging … doesn’t anyone do any physical examination or observation anymore?”.
Pediatr Radiol (2009) 39:500–505
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En niños con sospecha de apendicitis aguda cual es el rol de ECO y TAC ?Recomendación Nivel A – NingunaNivel B – ECO confirma, pero no excluye. TAC abdominopelvico confirma y excluye la apendicitis. Nivel C – Concerniente a la exposición a radiación ionizante. DX incierto con el ECO, TAC.
Annals of Emergency Medicine Volume 55 N 1 – Enero 2010
Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis
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IMAGENES
ECOGRAFIA ABDOMINALT.A.C.R.N.M.RAYOS X
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Sonographic technique Puylaert proposed the sonographic gradedcompression technique for diagnosis of appendicitis in 1986
Puylaert JBCM. Acute appendicitis: US evaluation using graded compression. Radiology 1986;158:355–60.
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R A D I O L O G I CC L I N I C SO F N O R T H A M E R I C ARadiol Clin N Am 45 (2007) 411–422
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R A D I O L O G I CC L I N I C SO F N O R T H A M E R I C ARadiol Clin N Am 45 (2007) 411–422
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R A D I O L O G I CC L I N I C SO F N O R T H A M E R I C ARadiol Clin N Am 45 (2007) 411–422
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R A D I O L O G I CC L I N I C SO F N O R T H A M E R I C ARadiol Clin N Am 45 (2007) 411–422
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sin embargo podemos categóricamente afirmar que sólo dos métodos son de valor practico: la ecografía y las puntuaciones. Con ellos se reduce en forma sustancial las laparotomías negativas, la observación prolongada y la incidencia de perforaciones.
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HALLAZGOS OPERATORIOS
NO Complicado 68%
Complicado 32%
HUEM - 2009REVISION 207 OPERADOS.
Complicaciones
Infección Herida 10%Absceso Pared 7%Absceso Residual 2%Obstrucción Intestinal 1%Reintervención 3%
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The use of morphine in children with a presumptive diagnosis of appendicitis did not delay the surgical decision. In our group of patients, however, morphine at a dose of 0.1 mg/kg was not more effective than placebo in diminishing their pain at 30 minutes. [Ann Emerg Med. 2007;50:371-378.]
Efficacy and Impact of Intravenous Morphine Before Surgical Consultation in Children With Right Lower Quadrant Pain Suggestive of Appendicitis: A Randomized Controlled Trial
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Comparison of Four Pain Scales in Children With Acute Abdominal Pain in a Pediatric Emergency Department2007 by the American College of Emergency Physicians.
For early analgesia in appendicitis, we did not find an association with delayed treatment for opiate analgesia, but there did appear to be an association with nonsteroidal anti-inflammatory analgesia .American Journal of Emergency Medicine (2008) 26, 176–180
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A QUE HORA LA CIRUGIA ?.
Taylor M, Emil S, Nguyen N, Ndiforchu F. Emergent vs. urgent appendectomy in children: A study of outcomes. J Pediatr Surg 2005;40:1912–1915.
Styrud J, Eriksson S, Nilsson I, et al. Appendectomy versus antibiotic treatment in acute appendicitis. A prospective, multicenter, randomized, controlled trial. World J Surg 2006;30:1033–1037.
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Yardeni D, Hirschl RB, Drongowski RA, Teitelbaum DH, Geiger JD, Coran AG. Delayed versus immediate surgery in acute appendicitis: Do we need to operate during the night? J Pediatr Surg 2004;39:464–469.
Bennett J, Boddy A, Rhodes M. Choice of approach for appendicectomy: A meta-analysis of open versus laparoscopic appendicectomy. Surg Laparosc Endosc 2007;17:245–255.
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GRACIAS